Discharge Is a Critical Time to Influence 10-Year Use of Secondary Prevention Therapies for Stroke

Abstract

Background and Purpose— When optimally managed, patients with stroke are less likely to have further vascular events. We aimed to identify factors associated with optimal use of secondary prevention therapies in long-term survivors of stroke. Methods— We carefully documented discharge medications at baseline and self-reported use of medications at annual follow-up in the Northeast Melbourne Stroke Incidence Study (NEMESIS). We defined optimal medication use when patients reported taking (1) antihypertensive agents and (2) statin and antithrombotic agents (ischemic stroke only). Logistic regression was used to assess factors associated with optimal medication use between 2 and 10 years after stroke. Results— We recruited 1241 patients with stroke. Optimal prescription at discharge from hospital was the most important factor associated with optimal medication use at each time point: odds ratio (OR), 32.2 (95% confidence interval [CI], 13.6–76.1) at 2 years; OR, 7.86 (95% CI, 4.48–13.8) at 5 years (425 of 505 survivors); OR, 6.04 (95% CI, 3.18–11.5) at 7 years (326 of 390 survivors); and OR, 2.62 (95% CI, 1.19–5.77) at 10 years (256 of 293 survivors). Associations were similar in men and women. The association between optimal prescription at discharge and optimal medication use at each time point was greater in those who were not disadvantaged, particularly women. Conclusions— Prescription of medications at hospital discharge was the strongest predictor of ongoing medication use in survivors of stroke, even at 10 years after stroke. Ensuring that patients with stroke are discharged on optimal medications is likely to improve their long-term management, but further strategies might be required among those who are disadvantaged.

Quality of Acute Care and Long-Term Quality of Life and Survival

“…Overall, the patients managed on ASUs were less often discharged to institutional residential aged care (6% ASU versus 11% other wards, P<0.001) and more often accessed inpatient rehabilitation (37% ASU versus 22% other wards, P<0.001). (16) 2111 (15) 404 (16) 223 (27) IRSAD 2 3614 (21) 2875 (21) 495 (19) 244 (29) IRSAD 3 2173 (13) 1778 (13) 309 (12) 86 (10) IRSAD 4 3707 (21) 3026 (22) 523 (20) 158 ( (11) 1171 (9) 694 (27) 82 (11) Home 6603 (39) 5664 (41) 546 (22) 393 (51) Rehabilitation 5181 (30) 4389 (32) 705 (28) 87 (11) Institutional care 1014 (6) 777 (6) 176 (7) 61 (8) Hospital readmission within 90-180 d* 1577 (20) 1354 (20) 154 (19) 69 (23) Figure). Receiving care bundle (a) (ASU care) was strongly associated with greater 180-day survival (hazard ratio, 0.49; 95% CI, 0.43-0.56; Table 3) and HRQoL (Table 4).…”

Statin Adherence Is Associated With Reduced Recurrent Stroke Risk in Patients With or Without Atrial Fibrillation

“…15,16,21,22 The cohort presented here had, by comparison, unusually high levels of overall statin adherence; it is possible that the right-shifted distribution of PDC shown in Figure 1A may be because of the integrated nature of the healthcare delivery system from which the data are derived. Given that hospital discharge has been shown to be a critical moment to impact long-term adherence to the secondary stroke prevention strategies, 23 it is possible that our previously reported EMR intervention to increase statin prescription during stroke hospitalization 13 may have also contributed to long-term statin adherence in this cohort.…”

Secondary Prevention Three and Six Years after Stroke Using the French National Insurance Healthcare System Database

“…At 2 years, they observed that antiplatelet agents, warfarin, antihypertensive agents and statins had declined to 63.7, 45, 74.2 and 56.1% respectively. A more recent study looking at the use of secondary preventive treatment 10 years after stroke [11] found that the proportion of ­patients treated by antithrombotic drugs declined globally from 92 to 78% without further details. In contrast, compared to discharge, antihypertensive agent use increased from 58 to 74% and statin use increased from 21 to 48%.…”

“…A variety of therapies including antiplatelet drugs, antihypertensive agents and statins have clearly shown their efficacy in reducing the risk of vascular events in stroke patients [4]. Despite this evidence, there is a gap between guidelines and observed medication use: after a stroke, less than 50% of patients with known atrial fibrillation are on anticoagulant treatment, 70–85% of patients eligible for antiplatelet agents receive this treatment, 45–75% of patients are on antihypertensive agents and 20–50% of patients are on statins [5-11]. …”